影响断指再植成活率的多因素分析

目的 研究患的年龄、血红蛋白含量、吻合动静脉比例对断指再植成活率的影响。方法 回顾性分析1999年1月一2002年11月844例1231指的断指再植资料，对断指再植成活率与患的年龄、血红蛋白含量、吻合动静脉比例的关系进行统计学分析。结果 年龄因素不影响断指再植的成活率；急血红蛋白含量与断指再植的成活率呈明显正相关；甲根以远平面的断指再植用放血疗法的成活率明显低于吻合1条静脉的成活率；甲根至远侧指间关节平面的断指再植，吻合动脉数多于静脉数时，成活率明显下降；在中节和近节平面吻合动、静脉的比例数不影响成活率，但在近节平面吻合2条动脉的指端血运良好。结论 年龄不应作为筛选断指再植的条件；术后要注意及时纠正贫血；动静脉比例影响断指再植的成活率。     

吻合动静脉先后对断指再植成活的影响

目的比较吻合动静脉先后对再植手指成活与血管危象的影响。方法95例断指再植患者中先吻合动脉50例(先吻合动脉组),先吻合静脉45例(先吻合静脉组)。对两组再植成活率、静脉危象及动脉危象进行比较分析。结果患者均获得随访,时间2~6个月。先吻合动脉组成活42例,出现动脉危象7例、静脉危象5例;先吻合静脉组成活35例,出现动脉危象5例、静脉危象6例;两组成活率及动静脉危象发生率比较差异无统计学意义(P>0.05)。结论吻合动静脉先后对断指再植成活及出现血管危象无明显影响。     

Nonsurgical factors of digital replantation and survival rate: A metaanalysis

The aim of this metaanalysis was to evaluate the association between nonsurgical factors and survival rate of digital replantation. A computer search of MEDLINE, OVID, EMBASE and CNKI databases was conducted to identify literatures for digital replantation, with the keywords of “digit,” “finger” and “replantation” from their inception to June 10, 2014. Based on the inclusion and exclusion criteria, data were extracted independently by two authors using piloted forms. Review Manager 5.2 software was used for data analysis. The effect of some nonsurgical factors (gender, age, amputated finger, injury mechanisms, ischemia time and the way of preservation) on the survival rate of digital replantation was assessed. The metaanalysis result suggested that gender and ischemia time had no significant influence on the survival rate of amputation replantation. However, the survival rate of digital replantation of adults was significantly higher than that of children. The guillotine injury of a finger was easier to replant successfully than the crush and avulsion. The little finger was more difficult for replantation than thumb. Survival rate of fingers stored in low temperature was higher than that in common temperature. The present metaanalysis suggested that age, injury mechanism, amputated finger and the way of preservation were significantly associated with the survival rate of digital replantation.     

The effects of extreme cold on major extracranial arteries and veins

Summary Extreme cold has been focally applied to major extracranial arteries and veins in the cat. Reversible slowing of circulation and vascular occlusion have been shown to occur from this application. Following rewarming no acute changes within the lumen of the blood vessels have been observed radiographically and permanent thrombosis does not result after freezing of segments up to 30 minutes. Possible uses for this modality in cerebrovascular surgery are discussed.

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Zusammenfassung In Versuchen an Katzen wurden die Folgen umschriebener Einwirkung extremer Kälte auf extrakranielle Arterien und Venen untersucht. Es konnten damit reversible Zirkulationsverlangsamungen und reversible Gefäßverschlüsse hervorgerufen werden, bedingt durch ein Zufrieren der Gefäße. Nach dem Wiedererwärmen konnten angiographisch keine akuten Veränderungen des Lumens der Gefäße nachgewiesen werden. Es kam, selbst nach Einfrieren von Gefäßsegmenten bis zu 30 Minuten, nicht zu bleibenden Thrombosen. Die eventuellen Anwendungsmöglichkeiten dieses Verfahrens in der zerebralen Gefäßchirurgie werden diskutiert.

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Resumen El frio intenso ha sido aplicado localmente sobre las principales arterias y venas extracraneales del gato. Se ha demostrado que después de esta aplicación de frio se produce una lentificación reversible de la circulación y oclusión vascular. Posteriormente durante el recalentiamiento no se ha observado ningún cambio importante visible radiográficamente en el calibre de los vasos sanguineos y no se produjeron trombosis permanentes a consecuencia del enfriamiento de segmentos llegando hasta 30 minutos. Se discuten las posibles aplicaciones de esta técnica en cirugia cerebro-vascular.

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Résumé Le froid intense a été appliqué focalment aux artères et aux veines principales extracraniennes du chat. On a montré que le ralentissement réversible de la circulation et l'occlusion vasculaire se produisent à la suite de cette application. Pendant le réchauffement qui suit, aucun changement important n'est observé radiographiquement dans le calibre des vaisseaux sanguins et il ne se produit pas de thrombose permanente résultant du refroidissement des segments jusqu'à 30 minutes. On discute des usages possibles de cette technique en chirurgie cérébrovasculaire.

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Riassunto Il freddo spinto è stato applicato localmente alle principali arterie e vene nel gatto. Dopo questa applicazione è stato notato un rallantamento reversibile della circolazione sanguigna ed una occlusione vascolare.Dopo il riscaldamento non sono stati osservati radiologicamente cambiamenti acuti entro il lume dei vasi nè trombosi permanenti dopo aver raffreddato i vasi sino a 30 minuti. Le possibili applicazioni di questa metodica alla chirurgia cerebrovascolare sono discusse.

     

手指末节指掌侧浅静脉的显微解剖及临床应用

目的 研究手指末节指掌侧浅静脉分布规律,指导指末节离断再植术.方法 取100例手指标本分别进行乳胶灌注显微解剖法、断层解剖法、明胶-氧化铅灌注显微-解剖加X线摄片法研究指末节掌侧浅静脉的解剖学特点.临床对10例13指的离断末节指,进行吻合掌侧浅静脉的再植术.结果 在甲根水平通常可以找到1～3条指掌侧浅静脉,管径为0.2～0.5 mm.10例13指末节指离断再植均获成功.术后随访3～18个月,外观功能良好.结论 末节指掌侧浅静脉分布具有规律性,末节指再植吻合掌侧静脉有利于提高再植的成功率,并能减少其他静脉回流方法所带来的并发症.

Abstract：

Objective To study the anatomy of superficial palmar digital veins in fingertip,and explore the clinical application of superficial palmar digital veins as venous drainage in fingertip replantation.Methods One hundred fingers were studied with three methods: microanatomy,sectional anatomy,and X-ray.According to microanatomical observation,thirteen fingers in 10 cases with fingertip amputations and dorsal veins defect were replanted by anastomosis of palmar digital veins to reconstruct the venous drainage of the amputated digits. Results ( 1 ) 1 to 3 tiny superficial palmar digital veins can be found at the level of the onychorrhiza.The average diameters of the superficial palmar digital veins were 0.2-0.5 mm.(2)In clinical practice,13 replanted fingers were survived.After 3-18 months following-up,the appearance and function were satisfactory. Conclusion The distribution of the palmar digital veins was in some pattern.Anastomosis of the superficial palmar digital veins can not only improve the success rate of the fingertip replantation,but also avoid the complications of the other venous drainage methods.     

手指末节指掌侧浅静脉的显微解剖及临床应用

目的 研究手指末节指掌侧浅静脉分布规律,指导指末节离断再植术.方法 取100例手指标本分别进行乳胶灌注显微解剖法、断层解剖法、明胶-氧化铅灌注显微-解剖加X线摄片法研究指末节掌侧浅静脉的解剖学特点.临床对10例13指的离断末节指,进行吻合掌侧浅静脉的再植术.结果 在甲根水平通常可以找到1～3条指掌侧浅静脉,管径为0.2～0.5 mm.10例13指末节指离断再植均获成功.术后随访3～18个月,外观功能良好.结论 末节指掌侧浅静脉分布具有规律性,末节指再植吻合掌侧静脉有利于提高再植的成功率,并能减少其他静脉回流方法所带来的并发症.     

手指末节指掌侧浅静脉的显微解剖及临床应用

目的 研究手指末节指掌侧浅静脉分布规律,指导指末节离断再植术.方法 取100例手指标本分别进行乳胶灌注显微解剖法、断层解剖法、明胶-氧化铅灌注显微-解剖加X线摄片法研究指末节掌侧浅静脉的解剖学特点.临床对10例13指的离断末节指,进行吻合掌侧浅静脉的再植术.结果 在甲根水平通常可以找到1～3条指掌侧浅静脉,管径为0.2～0.5 mm.10例13指末节指离断再植均获成功.术后随访3～18个月,外观功能良好.结论 末节指掌侧浅静脉分布具有规律性,末节指再植吻合掌侧静脉有利于提高再植的成功率,并能减少其他静脉回流方法所带来的并发症.     

Type of injury and number of anastomosed vessels: impact on digital replantation

A retrospective study of 130 digital replantations was analyzed to identify factors influencing success rates. At the amputation between the middle phalanx and distal interphalangeal joint, it was found that type of injury and number of anastomosed vessels and veins were the most important factors. Amputations caused by mechanical crush reduced the number of available vessels for anastomoses. Having an anastomosed artery without any anastomosed vein significantly reduced the success rate compared with cases of amputation by knife or sawing machine, where at least an artery and a vein could be anastomosed. In replantation at the distal phalanx, only one anastomosed artery without any anastomosed vein could also result in high success. And in most cases of amputation between the proximal phalanx and proximal interphalangeal joint, there was no difficulty in finding at least an artery and a vein. Knowledge of anatomical transitions is therefore important for surgeons.     

Relaxant effects of propofol on human omental arteries and veins

We have investigated the relaxant effects of propofol on smooth muscle tension in human omental arteries and veins to determine if endothelium- related mechanisms are involved. Isolated vessel segments were precontracted with endothelin-1 and propofol was added cumulatively (10(-7)-10(-4) mol litre-1). In both artery and vein segments, propofol induced relaxation, which was not dependent on an intact endothelium. Relaxation was reduced when the extracellular K+ concentration was increased and in the presence of tetraethylammonium chloride (TEA). In intact segments, N-nitro-L-arginine methyl ester (L-NAME), indomethacin, glibenclamide, 4-aminopyridine, clotrimazole and atropine did not affect the concentration-response curve of propofol. This indicates that propofol relaxes human omental arteries and veins in an endothelium independent manner, and that hyperpolarization caused by activation of the K+ channel, BKCa, may be involved.      

Long-term effects of sensory reeducation following digital replantation and revascularization

The long-term maintenance of sensory gain following sensory reeducation is still unknown for replanted digits. Ten patients with 18 replanted or revascularized digits, who had received a formal sensory reeducation program for 1.5 years postoperatively, were reevaluated with moving two-point discrimination and Semmes-Weinstein pressure threshold test after discontinuing sensory reeducation for 1 year. Another four patients with seven replanted or revascularized digits, who have never received sensory reeducation after surgery, were also followed up in the same way. After cessation of sensory reeducation, the degree of moving two-point discrimination became significantly worse in the formal sensory-reeducated group (P < 0.05) and significantly improved in the group without sensory reeducation initially (P < 0.05), whereas it showed a nonsignificant change of Semmes-Weinstein threshold both in the group with formal sensory reeducation and without sensory reeducation. Sensory retraining did influence the progressive change of moving two-point discrimination, but not in a parallel way with the Semmes-Weinstein threshold test. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:334–336, 1998     

Use of volar veins in finger replantation

The number and the location of the venous anastomosis in finger replantation are discussed. The principle: 'two veins for one artery' has been given up in favour to do only one venous anastomosis. A vein on the palmar side should be preferred. Here the anastomosis is protected by a thicker layer of subcutanous tissue. In addition this technique allows to do the total vascular reconstruction without turning the hand. In a number of 84 finger replantations there was a failure rate of 9,5% by using only one vein for replantation. In 17 finger replantations using one volar vein we lost only one finger (5.9%).     

The role of allopurinol in digital replantation.

The clinical effects of allopurinol on the attenuation of reperfusion injury in thumb replantations after prolonged ischaemic time were studied in a randomized control trial with a 2-year follow-up. There were 60 patients, in the trial group, and 38 patients in the control group. All were young, healthy labourers who had sharp or locally crushed amputations of the thumb at the proximal phalanx with a total ischaemic time of more than 10 hours. The standard management for thumb replantation was used in these patients, except that 300 mg allopurinol was given orally in the trial group on admission and a further 300 mg for another 5 days. After operation, the trial group had a lower infection rate, and less postoperative pain and chronic swelling than the control group. Recovery of sensation was also better in the trial group.     

自我效能增强干预对断指再植成活率的影响

2005年3月～2008年10月,我院共收治断指患者90例(118指),运用自我效能增强干预对47例断指再植患者进行治疗观察,结果报道如下.     

The vascular complications of digital replantation.

A report on a series of 18 digital replantations is presented. The overall survival of digits was 13 (72%). All but one of the crush and avulsion amputations developed vascular complications. Venous insufficiency was much more commonly seen than arterial. Substantial blood loss was the rule in all digits which developed further vascular problems. A conservative approach is advocated for the majority of these complications.     

Heart transplantation in repaired transposition of the great arteries

Cardiac transplantation was carried out in a 40-year-old man with the diagnosis of repaired transposition of the great arteries and right-sided aortic arch who had end-stage cardiac failure due to myopathy of the ventricles. Because of several previous surgical repairs and the orientation of the great vessels, the operation presented some technical problems. Therefore, modifications of operative procedures were used, including recipient hypothermia, circulatory arrest, and changes in the donor heart implantation. The removal of the donor heart was modified in such a way that the graft included the aortic arch and both pulmonary arteries. With the extra length of ascending aorta and transverse arch, the innominate, left carotid, and left subclavian vessels were excised as a button, thereby leaving the distal orifice of the aorta in the superior portion of the transverse arch. For the recipient, the operation was performed using hypothermic total circulatory arrest to dissect free the huge pulmonary artery and the short right-sided aortic arch to place the clamp. Implantation of the donor heart was modified accordingly. The technical results were confirmed one and a half months later on a control digital angiogram. Thirty-five days postoperatively the patient was discharged. Six months after operation, the patient is doing better than ever before in his life. Our findings suggest that a complicated conotruncal development does not preclude cardiac transplantation.     

吸烟对断指再植手术的影响

随着断指再植技术的日臻完善 ,手术成功率呈上升趋势。尽管如此 ,仍有众多因素影响再植断指成活率 ,吸烟即是其中重要因素之一。为此 ,断指再植术后戒烟 (起码是一段时间内戒烟 )早已成为显微外科术后的常规“医嘱”。吸烟从哪些环节增加断指再植的失败机会 ?许多学者对此从不同方面作了研究 ,现将有关进展综述如下。1　尼古丁对微血管内皮细胞的毒理尼古丁是吸烟的主要危害因子 ,1支烟卷中尼古丁的含量可达 1 3ｍｇ〔1〕。研究发现 ,尼古丁对微血管的危害包括形态学及功能影响两方面。用烟草浸出液作皮内实验 ,发现血管闭塞性脉管炎患者阳…     

The hazard of cigarette smoking following digital replantation

Two case histories are presented in which cigarette smoking in the early postoperative period following digital replantation led to vasospasm and thus compromise of the microvascular anastomoses.     

用量化指标探讨断指再植的适应证

目的 确定影响断指再植成活的因素，进而用量化指标探讨断指再植的适应证。方法 分析1999年1月～2002年11月1231指的断指再植资料，对动脉损伤程度、指背皮肤损伤程度、损伤类型、离断平面、患者血红蛋白含量、骨与关节损伤程度、肌腱损伤程度、神经损伤程度、断指再通血时间进行评分并与断指再植成活情况进行Logistic回归分析。另外随机抽取再植成功和失败者各50例，与经过Logistic回归分析对断指再植成活确实存在影响的因素建立两分类判别方程。结果 动脉损伤程度、指背皮肤损伤程度、损伤类型、离断平面、患者血红蛋白含量对断指再植成活有明显影响，判别方程为Z：6．42Xl 5．31X2 4．35X3 3．26X4 3．15X5。结论 用量化可以判定断指再植的适应证。     

Venous flaps in digital revascularization and replantation

This is a report on 15 patients who underwent replantation/revascularization of a single digit with a substantial dorsal soft tissue defect. The dorsal defect was covered with a venous flap, a free flap that has only venous inflow and outflow. Postoperatively, the venous flaps were warm, pink, and appeared to exhibit a blanch and refill phenomenon, clinically resembling capillary filling. The flaps from the dorsal aspect of an uninjured digit had a survival rate of 100 percent, with no partial necrosis, while the flaps from a forearm or dorsal foot donor site failed. The advantages of using venous free flaps are twofold. Not only does this technique provide for venous drainage, but it also provides flap coverage and avoids complications, such as vessel occlusion or hematoma formation, associated with skin grafting over a venous anastomosis, with subsequent loss of the skin graft.